APPLICATIONS OF BOTULINUM TOXIN IN PHYSICAL MEDICINE ANDREHABILITATION

CONTENTS

Foreword xiGeorge H. Kraft

Preface xiiiIb R. Odderson

The Use of Botulinum Toxin in Pediatric Disorders 703Deborah Gaebler-Spira and Gadi Revivo

Botulinum toxins have an important role in the management ofchildren with hypertonia. This article reviews the impact of spastic-ity on growth and development and the orthopedic uses of botuli-num toxins and their expected outcomes. Specific considerationsfor injecting children are discussed, including evaluation, dosing,sedation, localization of the affected muscle, timing of physical mo-dalities such as electrical stimulation, casting, use of physical ther-apy, and some unique applications of botulinum toxin for childrenwith neurologic problems.

The Management of Oromandibular Motor Disorders andFacial Spasms with Injections of Botulinum Toxin 727Glenn T. Clark

The fact that a toxin produced by the anaerobic bacterium Clostrid-ium botulinum is able to block motor nerve conduction was discov-ered and converted to therapeutic use more than 3 decades ago.This block lasts 8 to 16 weeks with botulinum toxin type A. Thisarticle discusses the various disorders in the orofacial region forwhich botulinum toxin has been used.

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Botulinum Toxin Therapy for Cervical Dystonia 749Francis O. Walker

Botulinum toxin revolutionized the treatment of cervical dystonia.In contrast to systemically active medications, the effect of botuli-num toxin results from selective administration to weaken musclesinvolved in the dystonic posturing of the head. This article reviewsthe pathophysiologic basis of symptoms in cervical dystonia andhow botulinum toxin alleviates them. Other therapeutic optionsare reviewed for comparison. This article discusses strategiesfor maximizing the clinical benefit of botulinum toxin in this dis-order and reviews muscle selection and identification with electro-myography.

Botulinum Toxin for Spasmodic Dysphonia 767Arthur A. Rodriquez

Botulinum toxin is the accepted method of managing spasmodicdysphonia and has given most patients with adductor spasmodicdysphonia the ability to develop satisfactory vocal function. Re-sults have been less satisfactory in abductor spasmodic dysphonia.Management is accomplished best with a team approach. Thephysiatrist with experience in electromyography and botulinumtoxin usage can be a prominent member of this team.

The Importance of Electromyographic Guidance andElectrical Stimulation for Injection of Botulinum Toxin 781Martin K. Childers

The importance of electromyography (EMG) or electrical stimula-tion for guiding injections of botulinum toxin is based primarilyon preclinical data rather than on controlled clinical trials. Ques-tions remain about preferred administration methods. With thisin mind, the following injection techniques can be categorized:(1) areas of most active EMG motor unit firing (continuous noiseof motor unit firing), (2) motor end plates found in any muscleby EMG, and (3) motor points in the following muscles-biceps, del-toid, flexor carpi radialis, flexor digitorum sublimis, vastus inter-medius, sternocleidomastoid, palmaris longus, tibialis anterior,and brachioradialis.

Botulinum Toxin in the Management of Bowel andBladder Function in Spinal Cord Injury and otherNeurologic Disorders 793Dennis D. Dykstra

Botulinum toxin inhibits release of acetylcholine and other neuro-transmitters. It has been used successfully to treat pain and abnor-mal skeletal and smooth muscle activity in patients. This articlediscusses its use in patients with bladder and bowel disorders.

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Botulinum Toxins in Pain Management 805Mike A. Royal

The anaerobic bacterium Clostridium botulinum can produce sevendistinct botulinum toxins (BTs) that block acetylcholine releasefrom cholinergic nerve terminals, including preganglionic sympa-thetic and parasympathetic neurons, postganglionic parasympa-thetic neurons, and, perhaps most important from a therapeuticperspective, at the neuromuscular junction to produce a dose-dependent flaccid paralysis. When used therapeutically at appro-priate doses, BTs produce temporary effects with minimal risk ofsystemic adverse events. Although the cosmetic application (reduc-tion of facial wrinkling) of BTs has become the most widely knownuse, there has been tremendous interest in their potential for pro-ducing efficacy in various chronic pain syndromes. This article dis-cusses findings applicable to this growing area.

Use of Botulinum Toxin Type A and Type B for Spasticityin Upper and Lower Limbs 821Kathleen R. Bell and Faren Williams

Botulinum toxin is likely effective in controlling spasticity in thesmaller muscles of the arm and hand, although there has been onlyone large controlled trial. For lower limb spasticity, the outcomesare more mixed. No large randomized, controlled trials have beendone, and the larger size of the muscles results in a decreased abil-ity to treat widespread spasticity. For more focal treatment in thelegs and feet, however, and when combined with other denervat-ing agents or physical modalities, botulinum toxin is probably ef-fective. Careful analysis is warranted before performing anychemodenervation on a limb muscle or muscles.

Treatment of Hyperhidrosis and Drooling with BotulinumExotoxin 837Ib R. Odderson

Botulinum toxin is a new and effective treatment for focal hyper-hidrosis of the axillae, palms, forehead, and scalp, as well as treat-ment of gustatory sweating and drooling. This article reviews thecurrent treatments and outcomes achieved with chemodenervationof the eccrine sweat glands and salivary glands. Intracutaneous in-jections of botulinum toxin offer a simple, safe, and effective alter-native to other conservative and surgical options.

Muscle Overactivity and Movement Dysfunction in theUpper Motoneuron Syndrome 855Nathaniel H. Mayer and Alberto Esquenazi

The upper motoneuron syndrome (UMN) is a collective term thatrefers to different types of motor behaviors produced by patientswho have lesions of the descending corticospinal system. Lesions

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involving the upper motoneuron, its pathways, and its connectionscan occur at the level of the cortex, internal capsule, brain stem, orspinal cord. The clinical features of UMN have traditionally beenclassified as ‘‘positive’’ phenomena, referring to overt behaviorsgenerated by various forms of muscle overactivity, and ‘‘negative’’phenomena, referring to loss of overt behaviors secondary to im-paired muscle activation, impaired control of motor behavior,and impaired motor performance The clinical impact of UMN onpatients is broad and tends to limit functional capacity. The nega-tive and positive signs lead to reduced mobility and limb usage.

Botulinum Toxins in the Treatment of Migraine andTension-type Headaches 885Paul Winner

Botulinum toxins are promising preventive treatments for patientswith moderate to severe episodic and chronic migraine and chronicdaily headache. The recommended indications for botulinum tox-ins as preventive therapy lend themselves to the following patienttypes: those who demonstrate a lack of improvement from preven-tive (prophylactic) pharmacotherapy; those who experience severeand intolerable adverse events from preventive medications; thosewho refuse to use daily medications; those who have contraindica-tions to acute migraine therapy, and elderly patients with chronicmigraine. Both open-label and double-blind placebo-controlledstudies using fixed-site, ‘‘follow the pain,’’ or a combination ap-proach have demonstrated significant reduction in migraine fre-quency, severity, and duration, as well as decreased use of acutemedications.

Spinal Cord Injury and Use of Botulinum Toxin inReducing Spasticity 901Guy W. Fried and Karen Mandzak Fried

Spinal cord injury is a devastating neurologic condition, with spas-ticity being a common and often disabling sequela. The treatmentof spasticity in patients with spinal cord injury should be specificfor each patient and based on function. If conservative measuressuch as range of motion activities, and splinting do not adequatelycontrol spasticity, drug therapy is often undertaken. The use of bot-ulinum toxin is being explored as a treatment option, and it hasbeen used successfully in selected cases to control spasticity andimprove patient functioning with a duration of efficacy of approx-imately 3 months.

Cumulative Index 2003 911

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